Doctor-midwife tensions run deep

Stephanie Yao/The OregonianMelissa Cheyney, an assistant professor at Oregon State and a practicing midwife, conducts a prenatal care visit in a client's home.

Last week, midwives and clients of Andaluz Waterbirth Center in Portland announced plans to file a federal lawsuit to "cease intimidation and threats against midwives" by the Oregon Health Licensing Agency and Oregon Health & Science University.

Midwives say doctors and nurses at OHSU have filed baseless complaints to the licensing agency meant to thwart competition. Officials with the state agency and OHSU declined to comment on the allegations. The threatened lawsuit spurred a passionate online debate among supporters and critics of home birth.

Conflicts between midwives and doctors run deep. One of the biggest problems: Many physicians deal with midwives only when a laboring mother experiences difficulties during a home birth and requires transport to a hospital, sometime urgently.

"It's an extremely tension-fraught encounter," according to Melissa Cheyney, an Oregon State University assistant professor and practicing midwife who studied the interactions of midwives and doctors in Jackson County last year. Nearly every physician interviewed by Cheyney and her graduate student expressed the view that births must take place in a hospital to be "safe."

Studies including higher-risk pregnancies have found that fetal deaths are more likely in home births. But in low-risk pregnancies, most research shows no significant difference in risk to the baby, while home-birth mothers experience fewer complications. In a study in British Columbia last year, women giving birth at home suffered fewer than half as many serious perineal tears, and about a third less postpartum bleeding.

By choosing a hospital birth, women substantially increase the risk of having a surgical delivery. More than 29 percent of hospital births in Oregon resulted in a cesarean during the years 2006-2008. Less than 4 percent of home births ended with a cesarean in a 2005 study of 5,400 births attended by midwives in the U.S. and Canada.

Women who choose home birth often cite the desire to keep birth free of medical intervention. Heather Hermans, 27, of Portland said she transferred to the care of a midwife because she wanted to try a vaginal delivery rather than schedule a cesarean section, as her obstetrician-gynecologist recommended.

Hermans experienced complications during labor and took an ambulance to OHSU, where a surgeon delivered her healthy baby boy by emergency C-section. The surgeon filed a complaint about Hermans' midwife to the state – one of six complaints from doctors about midwives associated with Andaluz Waterbirth Center. Roy Haber, an attorney hired by the midwives, said the Oregon Health Licensing Agency withdrew all six investigations after he challenged them.

Conflicts aren't inevitable. Cheyney is working with midwives in Lane County and a Eugene obstetrician, Dr. Paul Qualtere-Burcher, on guidelines for smoother, more collaborative relations. Qualtere-Burcher and his colleagues have agreed to help midwives get access to laboratory testing and ultrasound screening for their clients. Midwives are referring higher-risk home birth clients to the physicians for assessment and another perspective.

"We'd like them to come in and see us before it becomes a big issue during labor," Qualtere-Burcher said. "I think it's been very successful."

Home birth by the numbers

Planned home births in Oregon last year: 877 out of 47,675 total births, or 1.8 percent.

Risk of baby dying in a midiwife-attended home birth: 1.7 percent versus 0.6 percent in hospitals, based on a 2009 British study including women with breech births, twins, or attempting a vaginal birth after a previous cesarean (VBAC).

Risk of baby dying in a midwife-attended home birth when comparing only low-risk mothers: 0.5 percent versus 0.3 percent in hospitals.

Chances of giving birth without medical intervention: 78 percent with a home-birth midwife versus 54 percent in hospitals, according to the 2009 British study.

A women's chances of having cesarean section when giving birth in an Oregon hospital, 2006-2008: 29 percent.

Long before there were hospitals and medical
doctors, women steeped in the traditions of midwifery took care of
laboring mothers and newborns. Midwifery has branched into different
forms. Here's a rundown:

Direct Entry Midwife -- A
general term for practitioners who train directly into midwifery without
a nursing or medical background, and attend births outside of
hospitals. Oregon law allows direct entry midwives to practice with no
licensure.

Certified Professional Midwife -- Direct
entry midwives certified by the North American Registry of Midwives,
which requires written and practical examinations and practical
experience attending 40 births.

Licensed Direct Entry
Midwife -- Direct entry midwives who obtain a license in Oregon are
authorized to use some prescription drugs and medical devices. They must
pass a national examination, demonstrate experience in attending
births, and complete continuing education every three years. They are
licensed by the Oregon Board Direct Entry Midwifery and subject to
disciplinary actions if they violate professional standards.

Certified
Nurse Midwife – Registered nurses who go on to complete an accredited
nurse-midwifery program. Oregon requires certified nurse midwives to
obtain a Masters degree. CNMs are the only midwives that practice in
hospitals. They are licensed by the Oregon State Board of Nursing.

To check credentials

Because
licensing is voluntary in Oregon, it's possible for a midwife who's
been stripped of a license for violations to continue to practice
legally. Midwives falsely claiming to be licensed have been fined
several times in recent years.

You can check on the status and
disciplinary history of a midwife at the website of the Oregon Health
Licensing Agency (click the "License Inquiry" tab at
left).